The Importance of Medical Records in Malpractice Cases

Your medical records are some of the most important documents in your life. Your healthcare team uses your files to track your health, inform other medical professionals about significant conditions, and provide you with informed, helpful care. However, your medical records can also play an important role when you aren’t receiving necessary care.

Accessing your healthcare documents is fundamental to filing a successful medical malpractice lawsuit. Below, you’ll learn what these records include, how they’re protected by law, and how to use them in your malpractice case to fight back against negligent healthcare professionals.

What Is Included In Your Medical Records?

Medical records are supposed to be systemic, inclusive documentation of your entire medical history. Healthcare workers are professionally obligated to add notes to your files every time you receive healthcare. That includes your regular annual checkup, an emergency room visit, or every bit of care you receive during an extended stay at the hospital.

Your files include a lot of very personal information about you. Most healthcare record files should contain:

  • Your contact information and demographic details
  • Your insurance and payment information
  • All consent, authorization, and release forms you’ve signed
  • Your family medical history
  • Your treatment history, including histories of illness, surgeries, physical exams, vaccinations, and general health habits
  • Your medication lists
  • Progress notes on your treatment while in in-patient care
  • Doctor’s orders, referrals, and prescriptions
  • Test results
  • Nursing notes for routine care

Your records should give a comprehensive overview of your health and detailed explanations of the treatments and care you’ve received.

How HIPAA Protects Your Private Information

Because of all the sensitive information in your files, the federal government instituted the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Under HIPPA, healthcare professionals are required to protect sensitive patient health information or face serious legal consequences.

HIPAA specifically covers protected health information (PHI), defined as personally identifiable or recognizable information disclosed to a healthcare worker while receiving treatment. PHI includes literally any information about your health if it’s connected to information like your:

  • Name
  • Birthday
  • Contact information
  • Location beyond the state level
  • IP address
  • Diagnostic codes
  • Dates of treatment
  • Insurance numbers
  • Photograph

Even out-of-date information like old phone numbers is still considered PHI. Under the HIPAA privacy rule, covered entities must give you full access to your records upon request or transmit those records to the entity you designate. Your right to this information never disappears; as long as your healthcare provider stores the records somewhere, they must give you a copy upon request. The only exceptions are psychotherapy notes and information specifically collected for use in legal proceedings.

Medical Records in Malpractice Cases

Your right to copies of your records is invaluable for proving medical malpractice. Your records are crucial evidence of the treatment you did or didn’t receive.

For example, suppose you suffered from a crucial heart attack misdiagnosis at the ER that left you with permanent heart damage. Your files will include notes from the intake nurse on your symptoms as well as the decisions of the doctors that misdiagnosed you.

It’s common for records to show that patients complained of common heart attack symptoms like chest pain and shooting pains in their left arm, and the doctor didn’t do their due diligence before diagnosing them with a panic attack. If that’s the case, your records will be vital for proving your malpractice claim.

Records can also demonstrate that you failed to receive the appropriate standard of care. During in-patient treatment, healthcare professionals must check specific vitals on all of their patients at regular intervals. They are also obligated to help patients remain hygienic and respond to changes in their conditions. If your files don’t reflect the correct vital measurements or other necessary care, they demonstrate that you were neglected.

How to Access Your Medical Records Correctly

If you believe you’ve been a victim of malpractice, one of the first things you should do is get copies of your medical history from the negligent provider. You can request them yourself or give written permission to your chosen advocate, such as an experienced medical malpractice attorney. To get your records, you’ll need to:

  • Fill out the provider’s request form. Most healthcare organizations offer a specific record request form. If not, you can send a letter to the provider specifying your name, SSN, birth date, contact information, and the files you’re requesting. If you’re concerned about having your request ignored, send the form or letter by certified mail, so you have proof it was received.
  • Wait. In California, providers must allow you to see your files within five business days of receiving your request. The provider has 15 business days to provide copies if you request them.
  • Pay the cost of service. California permits healthcare organizations to charge a “reasonable fee” for making copies of your files. You may be charged up to $0.25 per photocopied page or $0.50 per microfiche copy, as well as a reasonable clerical fee. For this reason, many experienced medical malpractice attorneys opt to see the records in-person and make their own copies.

Once you have copies of your medical files, you can do whatever you want with them. Remember to treat them carefully and store them somewhere secure because they contain sensitive personal information. A great option is to give them to your attorney for safekeeping and to make them easier to reference for your case.

Make the Most of Your Right to Your Medical Files

If you’ve been the victim of medical malpractice, you have every right to fight back against your mistreatment. The first step is getting copies of your medical files so you and your attorney can build your case.

If you’re ready to take action against neglectful medical professionals, you can start by scheduling your consultation with the expert team at the Law Offices of Michael Oran, APC. We will help you get copies of your files, build your case, and take your claim to court. Get in touch to learn how we can help you hold negligent healthcare workers accountable for their actions.

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